At Any Age, It Does Matter:
Substance Abuse and Older Adults (for Professionals)

Supplements

Sedative-Hypnotics

Sleep disturbances are a common complaint among older adults. They occur in about half of Americans over age 65 who live at home and in two-thirds of those in long-term care facilities.

Complaints about insomnia increase with advancing age. They occur in conjunction with a variety of psychiatric, medical, and pharmacological problems. Sleep problems may also result from the changing circadian rhythms that accompany the aging process.1-3

Benzodiazepines have replaced older and more toxic hypnotics (e.g., secobarbital, ethchlorvynol, glutethimide), which have a high addiction liability and difficult-to-treat overdose potential. They also tend to accumulate in older adults with chronic dosing as their capabilities for drug absorption and elimination diminish.4,5 Nearly two out of five prescriptions for benzodiazepines (38 percent) in 1991 were written for older patients.1,2

The shorter acting hypnotic benzodiazepines are generally favored over longer acting ones. The longer acting drugs tend to accumulate in older adults and produce undesirable effects in the central nervous system. Today, the most commonly prescribed hypnotic benzodiazepines include temazepam (Restoril) and triazolam (Halcion). These are also used as anxiolytics.1

Commonly Prescribed Sedative/Hypnotics

Class Drug Brand Name Elimination Half-Life for Older Adults*
Benzodiazepines Flurazepam Dalmane 72 hours, with short- and long-acting active metabolites
Prazepam Centrax Less than 3 hours, with long-acting active metabolites
Quazepam Doral 25-41 hours, with long-acting active metabolites
Temazepam Restoril 10-20 hours
Triazolam Halcion 2-6 hours, with reports of clinical effects up to 16 hours following a single dose
Imidazopyridine Zolpidem Ambien 1.5-4.5 hours (longer in older adults)
Chloral derivatives Chloral hydrate Noctec 4-8 hours (loses effect in 2 weeks)
Antihistamines Hydroxyzine Atarax 1-3 hours
Diphenhydramine Benadryl (nonprescription) 8-10 hours
Doxylamine Unisom (nonprescription) 8-10 hours

*Refer to product information insert for each drug as to its suitability for use in older adults.

Unfortunately, hypnotic benzodiazepines tend to be prescribed longer than needed for efficacy. This situation often leads to the well-known drawbacks of withdrawal and rebound insomnia.1 In 1990, for example, 23 percent of adults who used benzodiazepine hypnotics (mostly the short-acting triazolam) had used them nightly for at least 4 months.6

Sleep Patterns in Older Persons

Aging changes sleep architecture by decreasing the amount of time spent in the deeper levels of sleep (stages 3 and 4). In addition, the number and duration of awakenings during the night increase.

These new sleep patterns do not appear to bother most medically healthy older adults who recognize and accept the changes.2,3 Insomnia complaints among older adults are usually associated with a secondary medical or psychiatric disorder, psychosocial changes and stressors, and the use of medications that interfere with sleep.2,3

Among the drugs causing poor sleep patterns are:

Sleep apnea, in particular, may be aggravated by the use of a benzodiazepine.7 Insomnia has also been related to: Sleep disruption and anxiety commonly accompany other psychosocial adjustments such as retirement, bereavement, dislocation, and traumatic situations.2,3 Sleep complaints are also associated with female gender, living alone or in a nursing facility, activity limitations, and sleep habits such as excessive daytime napping.3

Treatment of Insomnia

With respect to treatment of insomnia, the National Institutes of Health has specifically cautioned against relying on hypnotic benzodiazepines as the mainstay for managing insomnia.2 These medications can be useful for short-term treatment of temporary sleep problems. However, no studies demonstrate their long-term effectiveness beyond 30 continuous nights. In addition, tolerance and dependence develop rapidly.2,3,6

Symptomatic treatment of insomnia with medications should be limited to 7 to 10 days. Frequent monitoring and reevaluation are necessary if the prescribed drug will be used for more than 2 to 3 weeks. Intermittent dosing at the smallest possible dose is preferred, and no more than a 30-day supply of hypnotics should be prescribed.

Sedative-hypnotics, as well as benzodiazepines, used for sleep induction may cause confusion and equilibrium problems in older users who get up frequently during the night (e.g., to go to the bathroom). In treating older adults, clinicians should avoid situations likely to increase the incidence of falls. In addition, any alcohol used during the evening will increase the effect of drugs taken at night for sleep induction.

Withdrawal

Given the changes associated with drug metabolism among older patients, all hypnotic medications should be used with caution, especially those with long half-lives.1-3 Withdrawal effects signifying physiological dependence are common when medication use is stopped abruptly, especially with the short-acting compounds. The REM sleep rebound effects from abruptly stopping a chronically administered benzodiazepine hypnotic can last 1 to 3 weeks or longer.1,3

Withdrawal from sedative-hypnotic medications should be carefully monitored. Withdrawal is characterized by:

A grand mal seizure may occur in 20 to 30 percent of dependent persons if withdrawal symptoms are untreated. Hallucinations similar to those associated with alcoholic delirium tremens (DTs) may also be present.

Alternative Insomnia Treatments

Instead of relying on drugs as a first line of approach, clinicians should initially try to treat any underlying disorder (e.g., depression, alcoholism, panic states, anxiety).3 Having the patient keep a sleep diary may be useful for obtaining a more objective clarification of sleep patterns, because insomnia is notoriously subjective. Also, the importance of good sleep hygiene cannot be underestimated.1-3 Patients may need to be educated about:

Specific Drug Warnings

Several precautions about particular drugs should be noted. Specifically, triazolam (Halcion) rapidly achieved notoriety and was banned in the United Kingdom and other European countries after its 1979 introduction. The ban was based on reports of bizarre, idiosyncratic panic and delusional reactions as well as adverse side effects of confusion, agitation, and anxiety.8,9

More serious side effects are still more consistently and more frequently reported with triazolam than with temazepam (Restoril), a similar short-acting hypnotic benzodiazepine.8 Older patients appear more likely than younger ones to experience increased sedation and psychomotor impairment with this medication. They also report an increased incidence of adverse behavioral reactions. These occur when the dose is greater than 0.125 mg.1

Another recently introduced but popular hypnotic, zolpidem (Ambien), does not have the anxiolytic, muscle relaxant, or anticonvulsant properties of benzodiazepines. It has been touted as a safer sleep medication because it does not disrupt physiological sleep patterns at low doses and appears to have relatively mild, dose-related adverse effects.

One concern about zolpidem is that it is much more costly than benzodiazepines. This is an important consideration for low-income older patients. Also, lower doses (beginning at 5 mg) must be used in older patients to avoid hazardous confusion and falls.1,5,9,10 Because of its recent introduction, limited information is available on the possible undesirable effects of zolpidem for older patients.

Several antihistamines, usually used for relief of allergies and available as over-the-counter medications, are also taken as sleeping aids because of their sedating properties (e.g., Benadryl). Antihistamines are also combined with over-the-counter analgesics and marketed as nighttime pain medications (e.g., Tylenol PM). However, older adults appear to be more susceptible to adverse anticholinergic effects from these substances.

Older adults are also are at increased risk of hypotension and central nervous system depression or confusion from antihistamines. In addition, antihistamines and alcohol potentiate one another. These additive effects can worsen the above conditions as well as any problems with balance. Because tolerance develops within days or weeks, these antihistamines have questionable efficacy and are not recommended for older adults who are living alone.1,2,5,10

References

  1. Fouts, M., and Rachow, J. Choice of hypnotics in the elderly. P-T News 1994, 14(8):1-4.
  2. National Institutes of Health. Consensus Development Conference Statement. The Treatment of Sleep Disorders in Older People 8(3):1-22, 1990.
  3. Mullan, E.; Katona, C.; and Bellew, M. Patterns of sleep disorders and sedative hypnotic use in seniors. Drugs and Aging 1994, 5(1):49-58.
  4. Solomon, K.; Manepalli, J.; Ireland, G.A.; and Mahon, G.M. Alcoholism and prescription drug abuse in the elderly: St. Louis University grand rounds. Journal of the American Geriatric Society 1993, 41(1):57-69.
  5. Bezchlibnyk-Butler, K.Z., and Jeffries, J.J., eds. Clinical Handbook of Psychotropic Drugs, 5th ed. Toronto, Canada: Hogrefe-Huber, 1995.
  6. Salzman, C. Issues and controversies regarding benzodiazepine use. In: Cooper, J.R.; Czechowicz, D.J.; Molinari, S.P.; and Petersen, R.C., eds. Impact of Prescription Drug Diversion Control Systems on Medical Practice and Patient Care. NIDA Research Monograph Series, Number 131. NIH Pub. No. 93-3507. Washington, DC: U.S. Government Printing Office, 1993, pp. 68-88.
  7. Culebras, A. Update on disorders of sleep and the sleep-wake cycle. Psychiatric Clinics of North America 1992, 15:467-489.
  8. Woods, J.H., and Winger, G. Current benzodiazepine issues. Psychopharmacology 1995, 118:107-115.
  9. Winger, G. Other abused drugs: Benzodiazepines and sedatives. In: Fourth Triennial Report to Congress on Drug Abuse and Drug Abuse Research From the Secretary, Department of Health and Human Services. Rockville, MD: U.S. Department of Health and Human Services, 1993.
  10. Ray, W.A.; Thapa, P.B.; and Shorr, R.I. Medications and the older driver. Clinics in Geriatric Medicine 1993, 9(2):413-438.
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